Congestive Cardiac Failure (CCF)

Acute Pulmonary Oedema (APO) vs Decompensated CCF

Definition:

• APO: Medical emergency with rapid onset of severe breathlessness, widespread lung crackles, and hypoxia

• Decompensated CCF: Gradual worsening of symptoms over days to weeks, often presenting with bilateral crackles and increased breathlessness

Initial Management of APO

• Positioning: Sit patient upright to reduce pulmonary congestion

• Transfer: Urgent ambulance transfer to ED with IV access using a large-bore cannula

• Medications:

  • Furosemide: 20 mg IV bolus or 40 mg PO, repeat after 20 mins if no response

  • GTN: 400 mcg sublingual (up to 3 doses)

  • Morphine: 2.5 mg IV slow bolus for symptomatic relief

• Monitoring: Continuous ECG, BP, O₂ saturations (aim >94%)

• Additional: Consider IDC for urine monitoring if indicated

Management of Decompensated CCF

• Outpatient Management: May be appropriate if clinically stable

• Diuretics: Increase current diuretic dose or start furosemide 20–40 mg PO daily

• Fluid Restriction: Limit to 1.5 L/day if symptomatic with fluid overload

• Follow-Up: Review within 24–48 hours; repeat CXR if required

Types of Heart Failure

Based on Ejection Fraction (EF):

• HFrEF: EF <40% (systolic dysfunction)

• HFpEF: EF >50% (diastolic dysfunction)

Based on Ventricular Dysfunction:

• Right-Sided HF: Peripheral oedema, elevated JVP, hepatomegaly

• Left-Sided HF: Pulmonary congestion, SOB, bilateral crackles

Investigations

Bedside:

• ECG, BP, O₂ saturations, urine output (use IDC if severe)

Bloods:

• FBC, UECs, LFTs, TFTs, BNP, troponin (if ?ACS)

Imaging:

• CXR: Pulmonary congestion, cardiomegaly, pleural effusions

• Echo: Assess EF%, structural abnormalities (e.g., valves)

Other:

• Coronary angiography if ischaemia suspected

Complications

• Pulmonary oedema

• Renal impairment (due to diuretics, low output, cardiorenal syndrome)

• Arrhythmias – AF, VT, sudden cardiac death

• Hepatic congestion → chronic liver disease

• Malnutrition and cachexia

Prognosis

• Dependent on NYHA class and EF%

  • NYHA I: Mild symptoms

  • NYHA IV: Severe symptoms at rest

• Median survival for HFrEF: ~5 years

Guidelines for Diuretics and Fluid Restriction

• Diuretics: Start furosemide 20–40 mg PO daily and titrate as needed. IV therapy for severe APO or acute decompensation

• Fluid Restriction: 1.5–2 L daily if symptomatic with fluid overload

Indications for Inotropes and Mechanical Circulatory Support

• Inotropes: Indicated in acute decompensated HF with cardiogenic shock (e.g., dobutamine)

• Mechanical Circulatory Support: LVAD or intra-aortic balloon pump for severe cases or as a bridge to transplant

Vaccination Recommendations

• Influenza Vaccine: Annually for all HF patients

• Pneumococcal Vaccine: Every 5 years to prevent respiratory infections

Optimisation of Medications and Monitoring Renal Function

• ACE inhibitors (ACEis)/ARBs: Start low, titrate to max tolerated dose. Monitor K⁺ and creatinine

• Beta-Blockers (BBs): Bisoprolol, carvedilol for stable HF. Gradually titrate dose

• Spironolactone: Add for EF <35%. Monitor K⁺ closely

• SGLT2 Inhibitors: Emerging role in HFrEF regardless of diabetes status

• Monitoring: Regular UECs and electrolytes (K⁺, Na⁺). Risk of hypokalaemia and AKI

Patient Education and Self-Management

• Advise patients to monitor weight daily; an increase of >2 kg over 2 days may indicate fluid retention

• Recommend a low-sodium diet to help manage fluid balance

• Emphasise the importance of taking medications as prescribed to manage symptoms and improve prognosis

• Educate patients on recognising early signs of decompensation, such as increased breathlessness or swelling

Lifestyle Modifications

• Strongly encourage quitting smoking to improve cardiovascular health

• Advise limiting alcohol consumption, as excessive intake can exacerbate HF symptoms and contribute to cardiomyopathy

• Encourage tailored physical activity based on functional capacity, avoiding excessive exertion in symptomatic patients

• Educate on the impact of stress on heart failure and encourage relaxation techniques